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Elimination 2


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Structure of Unrinary Tract
Kidneys, Ureters, Bladder, Urethra
-pair shaped organ
-on either side of verebrae column bet. 12 thoracic & 3rd lumbar vertebrae
Functional unit of the kidney
the nephron
-each kidney has 1 mil nephron capable of forming unrine
-storage compartment of uringe
-behind symphis pubis when empty
-in women: infront of uterus & vagina
-in men: infront of recturm and above prostate gland
- has 3 layers of muscle called Detrusor Muscles
narrowed smooth muscles; moves urine fro kidney to bladder
-exict pathway for uringe
-in women: shorter so increase risk for infections
-in men: longer; transport semen & urine
Function of kidney
-regulate fluid volume
-done by 2 process: urine formation & urine excretion
Urine formation
3 processes: filtration, reabsorption, secretion
Urine excretion
-involves micturation (voiding)
-adults usually void when bladder has 250-400 ml urine
Characteristics of normal urine
Volume: 250-400 ml
Color: light yellow to dark yellow to dark brown
Clarity: clear w/o sediment
Odor: aromatic
Normal urinary pattern
-most people void 6-8x daily
-total output in 24 hrs. 1200-1500 ml
-max. void = 200 ml
-min. void = 500ml
Life span consideration adult and older adult
-middle age men experience urinary incontinence relating to BPH (benign prosthetic hypertrophy)
-women: weakend perineal muscles
-cardiovascular changes
-decrease bladder capacity
-coronary artery disease meds. to control hypertension
-post menopausal due to decrease estrogen levels
Factors Affectin Urinary Elimination
Fluid intake: Intake correlates w/ output
-loss of blody fluid: sweat, vomiting, burns
-body position
-psychological factors : don't remember
-obstruction of Urine flow: kidney stones, large prostate
-neurology injury: injury of sacral nerve
-decrease muscle tone
-urinary diversions
-cardiovascular changes
Altered urinary function
Dysuria, polyuria, oliguria, anuria, urgency, frequency, nocturia, hematuria, pyuria, urinary retention, enuresis, incontinence, stress incontinence, urge incontinence, reflex incontinence, functional incontinence, total incontinence
Painful voiding
excessive amount of urine, usually around 2500-3000 ml/24 hr
decreas amount of urine, usually around 500 ml/24hr
urine output of less then 100 ml/24hr
voiding at frequent intervals
voiding at night 2 or more times
glood in the urine
pus in the urine
Urinary retention
inability to empty the bladder
bed wetting
Incontinence: 5 types
involuntary loss of urine
5 types: stress, urge, reflex, functional, total
Stress incontinence
sudden loss of urine ( may be caused by laughing, coughing sneezing)
Urge incontinence
inability to hold back urine when feeling the urge to void
Reflex incontinence
caused by spinal cord injuries leading to loss of voluntary control of the bladder
Functional Incontinence
the patient has normal bladder and sphincter control but can not reach the bathroom
Total incontinence
continuous, involuntary, unpredictable loss of urine
What is your normal bowel pattern

What things do you do to stay regular

Have you had any changes in your normal pattern

Do you have problems with nausea, vomiting, constipation or diarrhea

Have you had any problems with discomfort or control of your bowel movements.
Assessment of Elimination
-what is your normal voiding patterns
-have you experienced any changes in your usual voiding pattern
-have you had any discomfort, pain, frequency incontinence, or difficulty starting the urine stream
Assessment: Subjective
-normal pattern identification
-risk identification
-dysfunctional identification
Assessment: Objective
-assessment of urine
-intake and output
Physical Assessment
Inspection: no bladder distention (look above symphis pubis)
Percussion: Hollow sound
Palpation: Bladder is naot palpable
Diagnostic Test
-urine specimens: random,
- clean catch (free of microorganisms)
-24 hrs. (eeded for accurate measure of kidney excretion)
-blood test
-radiology procedures
-cytoscopy (pt. usually given antibiotic for 2 days after)
-urodynamic studies
Urinalysis Evaluation
-casts 9precipitation or clumping of protien substances)
-specific gravity
Specimen for Routine analysis U/A
-ideally well mixed, first morning (8 hr concentrated) uncentriguged specimen, tested at room temp
-ideally, specimen should be tested w/in 30 min of voiding, w/in 2 hrs. of collected
-specimens should not be accepted if left at room temp. for more than 2 hrs.
-any fresh random urine specimen is acceptable for chemical analysis
-if not possible to test U/A w/in 1-2 hrs, refrigerate asap
-refrigeration will < growth of bacteria, primary cause for decomposition of urine after its voided
GU Testing - Urine studies
U/A simplest
-color, turbidity, odor, specific gravity
-ph, protien, glucose, ketones (ketoacidosis), bilirubin, blood
-microscopically - RBCs, WBC, eptithelial cells, casts
GU Testing -Urine studies pH
-normally, pH of urine range bet. 4.6 and 8
-acidic: values < 7
-alkaline: values > 7
-diets and urinary output: vegetarian : more alkaline, high protein-more acidic
-urine specimens become more alkaline: (1) if allowed to stand unrefrigerated, esp. for > 1 hr
(2) if urea splitting bacteria are present (3) if specimen is left uncovered
-an alkaline urine promote cellular breakdown, therefore, abnormal urinary sediment (such as RBC may be missed on analysis if specimen is not covered & delivered to lab on time or refrigerated
Specific Gravity test
-measure the relative concentration, or density, the weight of a drop of urine as compared to distilled water
-specific graavity of wate is 1.000
-a wider rante (1.001-1.035) is possible in states of fluid restriction or fluid volume excess
-if renal function is normal, a change in the specific gravity of urine occurs when there is a need to excrete more or less water to normalize the serum
-increase SG =dehydration
-decrease SG = overhydration
are a byproduce of the incomplete metabolism of fatty acids
-**normally there are not ketones in urine
-you may see ketones in a pt. on starvation diet
-proteins such as albumin, is not normally present in urine
-protein in urine may occur w/ (a) infecton (b) stress (c)admin of certain meds (d) streuous exercise
-random protein does not imply renal disease
-persistent protein needs further workup, as 24hr urine collection for total protein
-**protein is probable the most significant single finding in detection & dx or renal disease
Urine Sediment refers to particles present in urine (1) cells, (2) bacteria, 93) crystals (4) casts
RBC: 0-3 (if increase possible bleeding going on, UTI infection, bladder trauma)
WBC: 0-5
Bacteria/yeast: none-few 9if increase, then infection)
Casts: none-occassional (if increase possible renal disease
Urine Culture
Urine Culture (clean catch/midstream)
-determines # and type of pathogens present
-clean catch specimen or catheterized specimen
24 hour urine collections
-collects often ordered for measurement of levels of urinary creatinine or urea nitrogen, Na, Ch, Cal, cathcholamine or other components
-for a composite urine speciment, all urine w/in the designated time frame must be collected
-if other voided or cathererized speciments must be obtained while collection is in progress, measure & appropriately document the amounts removed
-nurse instructs pt. to empty bladder & discard that urine. Nurse notes the start time.
-If pt. has F/C, nurse empties catheter, the tubing & draining bag at the designated start time
-urine collection must be free from any contamination-fecal, blood, toilet tissue
-24hr after the start time (for 24hr collection) instruct pt to again empty bladder & include ending urine speciment in the collection
GU Diagnostic Testing Blood Chemistries
Cr (creatinine)
-normal value 0.6-1.2 mg/dl
-indicates kidney ability to excrete creatinine (end product of muscle metabolism)
-good indication of renal function
-creatinine is a normal by product of muscle metabolism & is excreted by the kidneys (creatinine found in blood, urine, muscle tissue) at faily constant levles, regardless of factors such as fluid intake, diet or exercise
-it provides a measure of renal funciton that is relatively independent of the hydration status of the pt or the pt dietary intake
-BUN & Creatinine test usually done together
Nursing Diagnosis: Stress Incontinence
-stress incontinence is a state i which a persons experiences a loss of urine of less than 50ml occurring w/ increased abdominal pressure

Defining characteristics: reproted or observed dribbling w/ increased abdominal pressure

Related factors: changes in pelvic muscles, increased age
Nursing Diagnosis: Urge Incontinence
A state in which a person experience involuntary passage of urine occuring soon after a stron sense of urgency to void

Defining characteristics: urgency, frequency more than every 2 hours), bladder spasm, nocturia (voiding more than 2x a night), voiding small amounts less than 100ml or large amts 550ml and inability to reach the toilet

Related Faxctors: decrease bladder capacity, irritation of the bladder, consumption of alcohol, caffeine, incrased fluids
Nursing Diagnosis: Reflex Incontinence
involuntary ooss of urine

Defining characteristics: no sensation to void, no sensation of bladder fullness

Related factors: neurological impairment
Nursing Diagnosis: Functional Incontinence
The inability of a person to reach the toilet in time

Defining Characteristics: amount of time it takes to reach the bathroom

Related factors: altered environment, sensory, cognitive, or mobility deficits
Nursing Diagnosis: Total Incontinence
When a person experiencs a continouous and unpredictable loss of urine.

Defining Characteristics: unawareness of incontinence

Related Factors: neuropathy, trauma or disease that affets the spinal cord nerves
Nursing Diagnosis: Urinary retention
The state in which a person experiences incomplete emptying of the bladder

Defining Characteristics: bladder distention, small frequent voiding, or absence of urine dribbling

Related Factors: blockage, weak detrusor muscles, inhibition of the reflex arc
-the client will reestablis control over voiding
-the client will strengthen or maintain control adequate perineal muscle control
-the client will verbalize understanding of procedures necessary to promote optimal urinary function
Health promotion
-promote water intake
-prevent urinary tract infections
-promote optimal muscle tone
-measure to promote voiding eg. positioning
Nursing interventions
-bladder training
-habit training
-bladder crede (milking the bladder so pressure will cause pt. to void)
-external catheter/protective pants (used to maintain pt. integrity)
-urinary catheters (invasive, internal, sterile procecure)
**foley Cath. is #1 cause of nosocomical infection
*nephrosocmy tube -goes directly into renal pelvis; must never be clamp to prevent kidney damage)
Meds: Urinary antiseptics

Nirotfurantoin (Macrobid)
keep urinary ph in acid range w/ vit. C & cranberry juice; give w/ food; warn pt. drug may discolor urine
Meds: Sulfonamides

eg. Bactrim, Sepra
admin. w/ large amount of fluid (med may crystalize) maintain alkaline ph becuase these meds are more soluble in alkaline urine. Avoid food/fluids that acidify urine
-usually given in UTI
-give lots of fluid b/c meds. may crystalize
Meds: Urinary Analgesic

for pain or UTI. Teach pt. urine will be red orange
Meds: Cholinergic

Bethanechol chloride (urecholine)
never used in pt. w/ any possibility of bladder obstruction; ne4ver give IM or IV ( can lead to circ collapse)
Antispasmodics: Ocybutynin choloride (Ditropan)
not used w/ HTN (hypertension, GI/GU obstruction, glaucoma
not used w/ narrow angle glaucoma, obstruction
Meds: Lasix
Bowel Elimination
regular elimination of bowel waste products is essential for narmal body functioning

alteration can cause problems w/ the gastrointestinal an other body systems
Structures of the GI Tract
mouth, esophagus, stomach, small intestine, large Intestine, cecum, colon rectum
Abdomen: Right Upper quadrant
lower part of right kidney
Abdomen: Left Upper Quadrant
transverse colon
Abdomen: Right Lower quadrant
ascending colon
(cecum is part of ascending colon-softer, wider tube)
Abdoment: Left Lower Quadrant
descending & sigmoid colon
(sigmoid colon-firm narrow tube, normal to have hild tenderness on deep palpation)
Digestion: Mouth
begins in the mouth
Digestion: Esophagus-reflux
lower esophageal sphincter or cardi a sphincter betw. esophagus and stomach
-prevents bacward movemnet of fluids from stomach to esophagus
-antacids-reduce reflux
-fatty food, nicotine will increase reflux
Digestion: Stomach
HCl, mucous, enzyme pepsin, intrinsic factor
-HCl concentration -stomach acidity, acid base balance. foods changes chyme, semi fluid material
Digestion: Small Intestine
chyme leaves stomach, enters small intestine
-mixes w/ digestive enzyme (bile & amylase
-travels via small intest. to allow absorption of nutrition and electrolytes
-enxymes from pancrease (amylase) and bile form gall bladder released into duodenum
-enzymes break down fat, protein, Carb
-nutrients absorb by duodenum & jejunum
-ileum absorb vits, iron, bile salts

*Problem - when food is not broken down into chyme such as stomach removed, gastroplasty or gastritis causes rapid emptying
Digestion: Large Intestine
1. cecum
2. sigmoid colon
3. recturm

*responsible for absorption of water; primary bowel elimination
Digestion: Colon
absorption, protection, secretion, elimination

water, Na, Cl, absorbed by colon
Functions of GI Tract: Motility, Absorption, defecation
Motility: Segmentation: alternation contraction and relaxation of smooth muscles. Permits more complete digestion and absorption of nutrients
-peristalsis: propels the intestinal contents along the lenght of the small and large intestine

2. Absopriton - most nof nutrients and electrolyte absorption occurs in the duodenum and jejunum
-fluid and electrolyes occur in large intestine

3. Defecation - distenion of the rectal muscles trigger bowel elimination
Characteristics of Normal Feces
frequency - variable
color - brown
consistency - soft formed
shape - cylindrical
amount - 100g - 300g/ day
odor -aromatic; pungent
Normal Bowel pattern
-is individualized
- 1-2 bowel movement per day to 1-2 movements every 2-3 days
Lifespan considerations
In older aldults the normal aging process shlow GI motility so frequency of bowel movements normally decrease

-older adults need increase fluid intake and high fiber foods

-laxative use high in older adults
Factors affecting elimination
surgery & anesthesia (slows the GI tract)

**the most reliable indicatior of functional GI tract is gas
Manifestation of altered bowel function
Constipation: symptom, not a disease.
-Decrease frequency , prolonged or difficult passage of hard dry stools

Impaction: results of unrelieved constipation.
-Collection of hardened feces, wedged in the rectum

Diarrhea: increase in number of stools & the passage of liquid, unformed feces.

Incontinence: inability to control passage of feces & gas from the anus.

Flatulence: gas accumulates in lumen of the intestines.

Distention: accumulation of excessive amounts of air , liquid or solids.

Hemorrhoids: dilated, engorged veins in the lining of the rectum

**bloody stool usually associated w/ GI bleeding, colorectal cancer, hemorroids
Bowel Diversions
Stoma: portion of intestine brought through the abdominal wall.

Colostomy opening created using a portion of the large intestine.

Ileostomy :Opening created using the ileum
Abdominal Assessment
Contour: Convex or Flat
Symmetry: Symmetrical
Auscultation : BS every 5-15 sec in all quardrants.
Percussion : Hollow, tympany in LUQ( Stomach)
Palpation: Soft

Listen to the abdomen before percussion and feeling it because the latter maneuvers may alter the frequency of bowel sounds.
Abdominal Assessment: Auscultation Key Points
Listen for bowel sounds, note frequency & character. Normal sounds consists of clicks & gurgles, frequency estimated at from 5-30 sec. Borborygmi-loud prolonged gurgles of hyper peristalsis (stomach growling)

Bowel sounds may be altered in diarrhea, intestinal obstruction, paralytic ileus, peritonitis.

Paralytic ileus: absence of BS greater than 72 Hours
Cullen's sine
bluish discoloration of umblicus seen in inter abdominal bleeding
Turnern's sign
bruise like discoloration in flank areas - associated w/ retroperitoneal hemmorrage
Palpation : Key points
Light palpation to examine the abdomen

Depress the area 0.5-1 inch
This is used to assess skin temperature and moisture

Massage in a circular motion to detect abnormal masses, areas of discomfort

Deep palpation 1.5-2 inches
The purpose of deep palpation is to locate organs, determine the size of the organs and to detect masses
Percussion: Key points
Percussion provides information about the nature of the underlying structure
It is used to outline the size of an organ such as the bladder or the liver
Determines whether an organ is air filled, fluid filled or solid
Diagnostic Test and Procedures
Stool Specimens
Hemocult ( guiac) and stool culture

Radiological Procedures
- Barium Enema
- Small Bowel

Endoscopic Examinations
- Sigmoidoscopy
- Colonoscopy
- Esophagogastroduodenoscopy
Stool Specimens
Includes inspecting the specimen for consistency and color and testing for occult blood

Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and other substances; these tests require that the specimen be sent to the laboratory

Random specimens are promptly sent to the laboratory

Quantitative 24- to 72-hour collections must be kept refrigerated until they are taken to the laboratory

Some specimens require that a certain diet be followed or that certain medications be withheld; check agency guidelines regarding specific procedures
An examination of the upper GI tract under fluoroscopy after the client drinks barium sulfate

NPO after midnight prior to the day of the test

A laxative may be prescribed
Instruct the client to increase oral fluids to help pass the barium
Monitor stools for the passage of barium (stools will appear chalky white) because barium can cause a bowel obstruction

A fluoroscopic and radiographic examination of the large intestine after rectal instillation of barium sulfate
May be done with or without air
A fluoroscopic and radiographic examination of the large intestine after rectal instillation of barium sulfate
May be done with or without air

A low-residue diet for 1 to 2 days prior to the test
A clear liquid diet and a laxative the evening before the test
NPO after midnight prior to the day of the test
Cleansing enemas on the morning of the test

Instruct the client to increase oral fluids to help pass the barium
Administer a mild laxative as prescribed to facilitate emptying of the barium
Monitor stools for the passage of barium
Notify the physician if a bowel movement does not occur within 2 days
Also known as esophagogastroduodenoscopy (EGD)
Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters, and duodenum; tissue specimens can be obtained

NPO for 6 to 12 hours prior to the test
A local anesthetic (spray or gargle) is administered along with midazolam (Versed) IV (provides conscious sedation and relieves anxiety) just before the scope is inserted
Atropine may be administered to reduce secretions, and glucagon may be administered to relax smooth muscle

Client is positioned on the left side to facilitate saliva drainage and to provide easy access of the endoscope
Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen saturation; emergency equipment should be readily available

NPO until the gag reflex returns (1 to 2 hours)
Monitor for signs of perforation (pain, bleeding, unusual difficulty swallowing, elevated temperature)
Maintain bed rest for the sedated client until alert
Lozenges, saline gargles, or oral analgesics can relieve minor sore throat after the gag reflex returns
Use of a rigid scope to examine the anal canal; client is placed in the knee-chest position with the back inclined at a 45-degree angle
Use of a flexible scope to examine the rectum and sigmoid colon; client is placed on the left side with the right leg bent and placed anteriorly

Biopsies and polypectomies can be performed
Nursing Diagnosis
Risk for or impaired skin integrity related to:
Fecal incontinence

Body image disturbance related to:
Presence of ostomy
Fecal incontinence
Nursing Interventions for Health Promotion
Client teaching
- Diet
- Fluids
-Activity and Exercise
- Bowel Habits
- Colorectal Screening
Screening for Colon Cancer
Risk Factors
Age: over 50
Family history: colon polyps or colorectal cancer
History of inflammatory bowel disease (colitis, Crohn’s disease)
Living in urban area
Diet: high intake of fats, low fiber intake
Warning Signs
Changes in bowel habits
Rectal bleeding
Screening Tests
Digital rectal examination every year after age 40
Guaiac test for occult blood every year after 50
Proctoscopy every -3-5 years after age 50, after two annual negative exams.
Nursing Interventions for altered Bowel Function
Medication Use
Rectal Tubes
Nasogastric Intubation
Fecal Impaction removal
Bowel Training
Fecal Diversions
Goals of Care for clients with elimination problems include the following:
Understanding “normal” elimination
Attaining regular defecation habits
Understanding and maintaining proper fluid and food intake.
Achieving a regular exercise program
Achieving comfort
Maintaining skin integrity
Maintaining self-concept
Promotion of regular bowel habits
Promotion of normal defecation
Squatting position
Positioning the bedpan
Cathartics and laxatives
Antidiarrheal agents
Types: SSE (cleansing), fleets, mineral oil, tape water, oil-retention, carminative, return-flow, medicated
Digital removal of stool
Bowel training
Medications For Constipation
-Bulk: metamucil attract water into the large intestines

-Stool softeners: Colace allows water to enter the stool easily

-Saline: MOM Increases colon motility through release of cholecystokinine.

- Stimulant:- Ducolax_ direct stimulation of the intestine mucosa
Medications For Diarrhea
-Absorbents: Pepto Bismal Absorbs excess fluid

-Bulk Forming Agents: Psyllium Attracts water to absorb excess fluids

- Opiates: Codeine: Increase H2O and electrolyte absorption

-Synthetic Agents: Immodium: Decrease intestinal motility

-Antispasmodics: Atropine Decreases intestinal Motility
Client will be able to regularly defecate soft formed painless stools.

Client will be able to accomplish normal defecation by manipulating natural components of daily living such as diet, fluid intake and exercise.

Client will have minimal reliance on artificial means of defecation such as enemas and laxative use.

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